Laparoscopic excision of retro pancreatic retro portal schwannoma.

Abstract

Schwannomas are usually benign tumors that arise from the schwann cells in the neural sheaths of peripheral nerves. Most schwannomas occur in the head, neck, or limbs and less commonly in the retroperitoneal space.1 In the retroperitoneal space, schwannomas are most commonly located near the adrenal gland. Retro pancreatic schwannoma is extremely rare2. Despite the widespread acceptance of laparoscopic resection of abdominal tumors, few cases of laparoscopic removal of retroperitoneal schwannoma have been reported and only one case of laparoscopic retro pancreatic tumor resection has been reported. Case report A 32 year old male presented with epigastric pain radiating to back associated with post prandial abdominal fullness of 1 year duration. On clinical examination, there was mild tenderness in right upper quadrant of abdomen. Ultrasound abdomen showed 3 x 2.5 x 2 cm size enlarged lymph node right to celiac axis. CECT abdomen revealed well defined hypoechoic 3 x2.8x1.8 cm size lesion situated at retro pancreatic region, posterior to main portal vein in aorto-caval groove (Figure 1). He was further evaluated with EUS, which confirmed CECT finding. EUS guided FNAB reported spindle cell neoplasm. Tumor was positive for sox-10, S 100 and alpha inhibin suggestive of a schwannoma. After preoperative assessment, patient was taken up for laparoscopic excision. The ports were placed as: 1 x 12 mm optic port, 2 x 10 mm multiport in para rectus and 2 x 5 mm port mid clavicular line in hypochondrium. The lesser sac was entered through the gastrocolic omentum and duodenum was kocherized up to aortocaval groove. Tumor was identified and it was dissected from adjacent portal structures ventrally and aorta and IVC dorsally using bipolar vessel sealing device. Total operative time was 115 min, with minimal blood loss. Specimen was retrieved from umbilical incision. Patient was discharged on Post-operative Day 3 after starting semisolid diet. Discussion Schwannoma is the exclusive neoplastic appandage of Schwann cells. Mostly benign, its malignant counterpart has high metastatic potential and an ominous prognosis. While retroperitoneal location is fairly rare accounting for nearly 2.7 per cent of all neurilemomas, retropancreatic location is extremely rare. The largest series of retroperitoneal schwannomas consisted of 82 cases and was reported by Li and colleagues in 2007; however, none of these neoplasms was described to be posterior to the pancreatic head1. Paolo et al summarized only three cases suiting the classification of retropancreatic schwannoma (behind the pancreatic caput, isthmus, and corpus, respectively)2–4. Currently, a laparoscopic approach is commonly described for retroperitoneal schwannomas of the pelvic region. With the increase in the experience as well as technological advances in minimally invasive surgery, it is now feasible to selectively resect lesions in difficult locations like the retroperitoneal region. As the retroperitoneal region is bounded by critical structures like porta and branches of celiac axis, superior mesenteric vessels, the duodenum, pancreas and aorta, IVC and kidneys posteriorly, accurate preoperative planning is crucial to assess relationship to these structures. Perhaps, smaller lesions and well encapsulated tumors are a good choice for laparoscopic excision. In addition, Laparoscopy with its magnified visualization, may aid in complete resection of these lesions. As compared to previous case reported by Rao et al3, operative time, blood loss and postoperative stay were significantly less. Caution should be exercised as significant experience with minimally invasive skill is mandatory before embarking upon this kind of surgery. Size of schwannoma is usually less than 5 cm, so size of incision for tumor retrieval is not major problem. In our case we retrieved tumor from umbilical port incision, so it was virtually scar less retrieval. Conclusion Laparoscopic excision is feasible in the treatment of retroperitoneal schwannoma, with the associated benefits of minimally invasive surgery. However, advanced laparoscopic skills, meticulous preoperative planning and intraoperative execution are necessary for a successful outcome.

Full text

Laparoscopic excision of retro pancreac retro portal schwannoma.
D Vaishnav, A Patel, R Solanki, M Narwaria.
Department of GI And HPB surgery, Asian Bariatrics, Ahmedabad, India.
Introducon
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Case report
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Discussion
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.!
>!66=?
;)
- 0
 2!@A
*
< 

B
#
 
:*
;
 
>-)
#$
-*
 - 
)
()9


Conclusion
> 
-3

 

Figuree 1
CT scan showing retroportal retro pancreac tumor.
Figure 2

Tumor freed from surrounding vital vasculature.
Intraop photograph.
>CD#%*E)E,#.!#4FE
!66=?==8!$=@A6
!3E#*/D
#!66?=G86!.@$6
$<<DH">
>+;,!66I?I8!@$
A434#EE*%!66.?$.8GAI
(;"
%;?THE AMERICAN SURGEON, January 2012 Vol. 78, E 41-42.